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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Modes of delivery for interventions to improve cardiovascular medication adherence

SL Cutrona, NK Choudhry, MA Fischer, A Servi, JN Liberman, TA Brennan, and WH Shrank.

Review published: 2010.

CRD summary

This review concluded electronic interventions, in-person pharmacist interventions at the site of medication dispensing and in-person interventions at hospital discharge showed the highest rates of success for improved adherence to cardiovascular disease medications Concerns about publication bias, the unclear quality of included data and imprecise methods of comparing data mean that the conclusions may not be reliable.

Authors' objectives

To determine the optimal modes of delivery of interventions aimed at improving adherence to medications for cardiovascular disease and diabetes.


MEDLINE and EMBASE were searched for peer-reviewed articles published between 1966 and December 2008. Search terms were reported. Only studies published in English were eligible for inclusion.

Study selection

Randomised controlled trials (RCTs) that lasted at least 24 weeks and assessed the effects of interventions to improve adherence to medications for prevention or treatment of cardiovascular disease or diabetes in adults were eligible for inclusion. The setting could be outpatient or in-patient/outpatient transition. Studies on regimen simplification (related to unit of use packaging or dose simplification) were excluded.

Among the included studies, the largest group of participants were on medication for hypertension; other groups included those with diabetes, coronary artery disease, congestive heart failure, dyslipidaemia and a mix of cardiovascular and non-cardiovascular diseases. Interventions consisted of providing paper, video, telephone or personal information/educational material, counselling, behaviour modification, home or tele monitoring, work-based interventions, pharmacy-based interventions and electronic systems (programmable pill boxes, automated phone calls, computer generated individualised interventions and home automatic blood pressure monitoring) or a combination of these. It appeared that the comparators were usual care or comparison between interventions. Measures of adherence included monitoring prescription refills, medication possession ratio, pill counts, medication electronic monitoring systems, electronic pill bottles and self-reported measures. Study length ranged from six months to three years. Most studies took place in North America or Western Europe.

The authors did not state how many authors performed study selection.

Assessment of study quality

The authors did not state that they assessed validity, except for a discussion on aspects of outcome measurement.

Data extraction

Data on effect size and confidence intervals (CI), where available, or p values were extracted by two authors. Disagreements were resolved by consensus.

Methods of synthesis

Results were reported in a narrative synthesis grouped by type of intervention. The numbers and percentage of studies that showed an improvement for each group were calculated. Differences between studies were discussed in the narrative.

Results of the review

Fifty-one RCTs (30,079 participants) were included. One study had 13,100 participants and others had 30 to 4,864 participants.

Non-personal interventions: (17 trials)

Three trials assessed paper, video or faxed delivered information. In one study that used letters to participants, people who received the intervention were more likely to adhere to medication. Two trials that used letters or videos showed no statistically significant effect.

Six trials assessed electronic systems. Four of these (on beeper pill caps, automated phone systems, computer generated reports and automated home blood pressure monitoring) showed improved adherence and two (on automated phone calls and decision analysis) showed no effect.

Eight studies assessed phone calls made by either trained lay people or professionals. Three of these showed a statistically significant improvement in adherence (one did not clearly define the outcome measure) and five showed no statistically significant improvement.

Face-to-face interventions: (34 trails)

Two trials of home visiting with family member involvement resulted in improvement in adherence. Two studies that did not include families showed no statistically significant effect.

Five of six trials that assessed interventions by pharmacists in a pharmacy showed improvements in adherence. Fifteen trials were conducted in a clinic setting. Five trials undertaken by pharmacists in clinics with dispensing facilities showed an improvement in adherence; three with no dispensing showed no statistically significant difference.

Two of three trials of physicians in a clinic showed improvements, but the methods of assessing adherence were not rigorous. Four of six studies that recruited participants at the point of hospital discharge showed an improvement in adherence.

Authors' conclusions

Electronic interventions, in-person pharmacist interventions held at the site of medication dispensing and in-person interventions at the point of hospital discharge showed the highest rates of success for improved adherence to cardiovascular disease medications.

CRD commentary

The aims of the review were clearly stated in terms of inclusion criteria. Only two relevant databases were searched. Only studies in English in peer-reviewed journals were eligible and it appeared that several papers in other languages were specifically excluded. Language bias and publication bias may have affected the results. It was unclear whether the review methods were those aimed at reducing reviewer error or bias. Study quality was not assessed (except for a discussion one outcome measures) and it was difficult to comment on the validity of included data.

A narrative synthesis appeared appropriate given the differences between studies. Synthesising results by simply counting studies took no account of differences in the magnitude and precision of observed effects. The included studies did not compare the different interventions directly. The authors acknowledged that there were problems with how adherence was measured in some studies, many of which used self-reporting.

Concerns about the quality of the included data, the possibility of publication bias and the imprecise methods of comparing data mean that the authors' conclusion may not be reliable.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that future research should explore new electronic approaches and in-person interventions at the site of medication distribution. A focus on identifying times of increased patient receptivity to adherence messages was important.


CVS Caremark, USA; National Heart, Lung and Blood Institute, USA.

Bibliographic details

Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, Shrank WH. Modes of delivery for interventions to improve cardiovascular medication adherence. American Journal of Managed Care 2010; 16(12): 929-942. [PMC free article: PMC3115758] [PubMed: 21348564]

Indexing Status

Subject indexing assigned by NLM


Antihypertensive Agents /therapeutic use; Cardiovascular Diseases /drug therapy; Communication; Diabetes Mellitus /drug therapy; Directive Counseling; Humans; Hypoglycemic Agents /therapeutic use; Medication Adherence /statistics & numerical data; Patient Discharge; Patient Education as Topic /methods; Pharmacies; Prescription Drugs; Professional-Patient Relations; Telephone; United States



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21348564


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